are categorized as penetrating or blunt trauma. Penetrating abdominal injuries (ie, gunshot wounds, stab wounds)
are serious and usually require surgery. Penetrating ab-dominal trauma results
in a high incidence of injury to hollow or-gans, particularly the small bowel.
The liver is the most frequently injured solid organ. In gunshot wounds, the
most important factor is the velocity at which the missile enters the body. High-velocity
missiles (bullets) create extensive tissue damage. All abdominal gunshot wounds
that cross the peritoneum or are as-sociated with peritoneal signs require
surgical exploration. Stab wounds may be managed nonoperatively.
to the abdomen may result from motor vehi-cle crashes, falls, blows, or
explosions. Blunt trauma is com-monly associated with extra-abdominal injuries
to the chest, head, or extremities. Patients with blunt trauma are a challenge
because of injuries that may be hidden and difficult to detect. The incidence
of delayed and trauma-related complications is greater than for penetrating
injuries. This is especially true of blunt injuries involving the liver,
kidneys, spleen, or blood ves-sels, which can lead to massive blood loss into
the peritoneal cavity.
In conjunction with the history, the abdomen is inspected
for ob-vious signs of injury, including penetrating injuries, bruises, and
abrasions. Abdominal assessment continues with auscultation of bowel sounds to
provide baseline data from which changes can be noted. Absence of bowel sounds
may be an early sign of intra-peritoneal involvement, although stress can also
decrease or eliminate bowel sounds. Further abdominal assessment may re-veal
progressive abdominal distention, involuntary guarding, ten-derness, pain,
muscular rigidity, or rebound tenderness along with changes in bowel sounds,
all of which are signs of peritoneal irritation. Hypotension and signs and
symptoms of shock may also be noted. Additionally, the chest and other body
systems are assessed for injuries that frequently accompany intra-abdominal
Laboratory studies that aid in assessment include the
Urinalysis to detect hematuria
(indicative of a urinary tract injury)
Serial hematocrit levels to
evaluate trends reflecting the presence or absence of bleeding
White blood cell count to
detect elevation (generally asso-ciated with trauma)
Serum amylase analysis to
detect rising levels, which sug-gest pancreatic injury or perforation of the
Hemorrhage frequently accompanies abdominal injury,
espe-cially if the liver or spleen has been traumatized. Therefore, the patient
is assessed continuously for signs and symptoms of exter-nal and internal
bleeding. The front of the body, flanks, and back are inspected for bluish
discoloration, asymmetry, abrasion, and contusion. Abdominal CT scans permit
detailed evaluation of ab-dominal contents and retroperitoneal examination.
Abdominal ultrasound studies can rapidly assess hemodynamically unstable
patients to detect intraperitoneal bleeding and pericardial tam-ponade. This is
referred to as the FAST (Focused Assessment for Sonographic Examination of the
Trauma Patient) examination. Pain in the left shoulder is common in a patient
with bleeding from a ruptured spleen, whereas pain in the right shoulder can
re-sult from laceration of the liver. Even though the patient com-plains of
pain, administration of opioids is avoided during the observation period
because their effect may obscure the clinical picture.
The abdomen is assessed
for tenderness, rebound tenderness, guarding, rigidity, spasm, increasing
distention, and pain. Referred pain is a significant finding because it
suggests intraperitoneal in-jury. To determine whether there is intraperitoneal
injury and bleeding, the patient is usually prepared for diagnostic procedures,
such as peritoneal lavage, abdominal ultrasonography, or abdom-inal computed
tomography (CT) scanning. Diagnostic
peritoneallavage involves the instillation of 1 L of warmed lactated
Ringer’sor normal saline solution into the abdominal cavity. After a min-imum
of 400 mL has been returned, a fluid specimen is sent to the laboratory for
analysis. Positive laboratory findings include a red blood cell count higher
than 100,000/mm3, a white blood cell count exceeding 500/mm3,
or the presence of bile, feces, or food.In patients with stab wounds,
sinography may be performed to detect peritoneal penetration. With this
procedure, a purse-string suture is placed around the wound, and a small
catheter is introduced through the wound. A contrast agent is then intro-duced
through the catheter, and x-rays are taken to identify any peritoneal penetration.
A rectal or vaginal
examination is performed to determine any injury to the pelvis, bladder, and
intestinal wall. To decompress the bladder and monitor urine output, an
indwelling catheter is inserted after a rectal examination (not before). In the
male pa-tient, a high-riding prostate gland (abnormal position) discov-ered
during a rectal examination indicates a potential urethral injury.
As indicated by the patient’s condition, resuscitation
procedures (restoration of airway, breathing, and circulation) are initiated. A
patent airway is maintained, and attempts to stabilize the respi-ratory,
circulatory, and nervous systems are made. Bleeding is controlled by
application of direct pressure to any external bleed-ing wounds and by
occlusion of any chest wounds. Circulating blood volume is maintained with
intravenous fluid replacement, including blood component therapy. The patient
is monitored for signs and symptoms of shock after an initial response to
trans-fusion therapy, because these are often the first signs of internal
With blunt trauma, the patient is kept on a stretcher to
im-mobilize the spine. A backboard may be used for transporting the patient to
the x-ray department, to the operating room, or to the intensive care unit.
Cervical spine immobilization is maintained until cervical x-rays have been
obtained and cervical spine injury ruled out.
Knowing the mechanism of injury (eg, penetrating force
from a gunshot or knife, blunt force from a blow), is essential to de-termining
the type of management needed. All wounds are lo-cated, counted, and
documented. If abdominal viscera protrude, the area is covered with sterile,
moist saline dressings to keep the viscera from drying.
Typically, oral fluids are withheld in anticipation of
surgery, and the stomach contents are aspirated with a nasogastric tube to
reduce the risk of aspiration. Nasogastric aspiration also decom-presses the
stomach in preparation for diagnostic procedures.
Trauma predisposes the
patient to infection by disruption of mechanical barriers, exposure to
exogenous bacteria from the en-vironment at the time of injury, and diagnostic
and therapeutic procedures (nosocomial infection). Tetanus prophylaxis and
broad-spectrum antibiotics are administered as prescribed.
Throughout the stay in
the ED, the patient’s condition is con-tinuously monitored for changes. If
there is continuing evidence of shock, blood loss, free air under the
diaphragm, evisceration, hematuria, or suspected or known abdominal injury, the
patient is rapidly transported to surgery. In most cases, blunt liver and
spleen injuries are managed nonoperatively.